Düzce Tıp Dergisi 2011; 13(1): 63-65 63
1Harun TOY
1Hakan CAMUZCUOGLU
1Mehmet VURAL
1 Department of Obstetrics &
Gynecology, School of Medicine, Harran University,
Submitted/Başvuru tarihi:
18. 08. 2009
Accepted/Kabul tarihi:
08 09 2009
Registration/Kayıt no:
09 08 64
Corresponding Address /Yazışma Adresi:
Dr. Harun TOY
Department of Obstetrics &
Gynecology, School of Medicine, Harran University, Diyarbakir yolu, yenisehir kampusu, Sanliurfa, 63100 Turkey.
e-posta:
haruntoy@hotmail.com
Abstract
Leiomyomas, or fibroids, are the most common benign tumors of the uterus. Pedunculated submucous myomas usually cause menstrual irregularities but rarely labor like pain through dilating the cervix and prolapsing through it with possible avulsion of the twisted necrotic prolapsed portion.
We present a case of pedunculated submucous myoma, mimicking cervical leiomyoma in a 30 year old unmarried virgin woman. She complained of occasional lower abdominal distention and menstrual dysfunction. The submucous pedunculated myoma was removed by laparotomy..
Prolapsed pedunculated leiomyomas of the uterus can best be managed by simple vaginal myomectomy. Cases like our patient can be difficult to manage because of not allowing vaginal excision.
Keywords: Prolapsed pedunculated submucous leiomyoma, myoma in statu nascendi, virgin woman
ÖZETLeiomyoma veya fibroidler uterusun en yaygın benign tümörleridir. Saplı submüköz leiomyomalar sıklıkla düzensiz menstruel kanamaya, nadiren genişlemiş serviks yüzünden bükülmüş nekrotik sarkan kısmın zorlanarak ayrılması ile doğum benzeri ağrıya neden olabilir.
Biz 30 yaşında evlenmemiş, bakire bir kadında servikal leiomyomayı taklit eden pedinküle submüköz myom olgusu sunuyoruz. Ara ara alt abdominal distansiyon ve menstruel düzensizlikten şikayetçiydi. Prolapse saplı submüköz Leiomyoma laparotomi ile alındı.
Uterusun prolapse pedinküle myomlarına en iyi yaklaşım basit vaginal myomektomidir. Bizim olgumuz gibi olgular, vaginal eksizyona izin vermediğinden dolayı yönetim zordur.
Anahtar sözcükler: prolapse saplı submüköz leiomyom, bakire kadın, myoma in statu nascendi
INTRODUCTION
Uterine leiomyomas (fibroids or myomas) are benign tumors that arise from the smooth muscle cells of the human uterus. Incidence in women of reproductive age is estimated to be 20–25 % (1). Leiomyomas may cause a variety of clinical symptoms: abnormal menstrual bleeding (menorrhagia with secondary anemia, dysmenorrhea), pelvic pressure due to their mass effect (urinary frequency, constipation, pelvic pain, dyspareunia) and infertility (2).
These symptoms can differ related to origin site accordingly. Prolapsed submucous fibroids are not an uncommon finding in young women of fertile age. Of the myomas, 5 % are submucosal, and 1.3% to 2.5% are pedunculated submucous myomas (PSMs). Among these PSMs 19.2% to 26.1% measured to be greater than 3 centimeters (3). They may be either ordinary fibromyomas of any size, or else occur as necrotic, degenerated or torsioned tumors. They are expelled by the uterus, and usually present in the vagina on a pedicle, following uterine contractions. PSMs rarely may induce labor like pain, eventually dilating the cervix and prolapsing through it with possible avulsion of the twisted necrotic prolapsed portion (3). Surgical removal of these fibroids is usually easy via vaginal approach by excision of the pedicle. However it is a handicap if the patient is virgin and not allowing for vaginal surgery.
Surgical Management of Prolapsed Pedunculated Submucous Leiomyoma in a Virgin Woman Bakire Bir Kadında Prolapse Saplı Submüköz
Leiomyomanın Cerrahi Yönetimi
2011 Düzce Medical Journal e-ISSN 1307- 671X www.tipdergi.duzce.edu.tr duzcetipdergisi@duzce.edu.tr
DÜZCE TIP DERGİSİ
DUZCE MEDICAL JOURNAL OLGU SUNUMU / CASE REPORT
Düzce Tıp Dergisi 2011; 13(1): 63-65 64
We present surgical management of a case with a different approach.
CASE REPORT
A 30 year old unmarried virgin woman referred to our clinic as a cervical leiomyoma case. In her personal history, she had uncommon lower abdominal pain and menstrual irregularities. She had not allowed for vaginal examination because of intact hymen. A transabdominal sonogram revealed a mass related with uterine cervix and with a diameter of 5 to 6 cm.
An abdominal exploration of this mass was planned especially for future reproductive ability. On abdominal exploration, the uterus was normal in size, but there was a solid mass extending from cervix to vagina. The bladder was decollated from the anterior
wall of the vagina. Approximately 4 cm vertical incision on upper and anterior part of vagina and 2 to 3 centimeters incision towards lower segment of the uterus was performed. There was pedunculated submucous myoma extending towards the whole vagina. Because of the thick pedicle of the fibroid, it couldn’t be excised from the cervix. Therefore lower uterine parts were also opened. The leiomyoma dilating the cervix and prolapsing through the vagina from uterine fundus with a size of 5 to 6.5 centimeters was resected by tying and cutting the pedicle. Then the vaginal and uterine anterior wall was repaired (Fig. 1). Postoperative period was uneventful and she was discharged in 4 days. She had no significant vaginal bleeding, pain and urinary symptoms. In the control visit a week later she had no complaint.
Harun TOY ve Ark.
Figure 1. A: Intra-operative view of pedunculated submucous myoma originating from lower uterine segments and extending towards vagina. Clamps are holding the cut edges of the uterine cervix.B: White arrow showing thick pedicle of the myoma, black arrow pointing the lower lip of the uterine cervix through which the pedunculated myoma is lying.C:
At the end of the wound closure with continuous vicryl sutures. Incision is like a cross. Lower part is related with upper portion of the anterior vagina.D: final view after peritoneal sutures.
Düzce Tıp Dergisi 2011; 13(1): 63-65 65
DISCUSSION
Several factors determine the treatment of uterine leiomyomas including the size and location, presenting symptom, age and reproductive desire of the patient and skill of the surgeon. Even if hysterectomy eliminates both the symptoms and the chance of recurrences, to increase chance of future pregnancies or wish to retain the uterus for other reasons myomectomy is widely done (1). Prolapsed pedunculated leiomyomas of the uterus can be best managed by simple vaginal myomectomy through cutting the pedicle. It is safe, easily performed and generally requires no anesthesia. By this way the risk of infection and hemorrhage of abdominal surgery can be avoided (4). Vaginal myomectomy is recommended as the initial treatment of choice for prolapsed pedunculated submucous myoma, except in those cases in which other indications necessitate an abdominal approach (5). In the single and virgin women we had to do abdominal operation both for the big size of the mass and intact hymen.
In conclusion, in some parts of our country intact hymen has a traditional importance especially before marriage. Therefore, although vaginal approach is a gold standard, abdominal management of the prolapsed pedunculated submucous leiomyoma can be performed in isolated special cases.
REFERENCES
1. Stewart EA: Uterine fibroids. Lancet, 357(9252):293-298, 2001.
2. Casini ML, Rossi F, Agostini R, Unfer V: Effects of the position of fibroids on fertility. Gynecol Endocrinol, 22(2):106-109, 2006.
3. Usta IM, Hobeika EM, Nassar AH: A tale of 2 pedunculated myomas. Am J Obstet Gynecol, 193(5):1753-1755, 2005.
4. Brooks GG, Stage AH: The surgical management of prolapsed pedunculated submucous leiomyomas. Surg Gynecol Obstet, 141(3):397-398, 1975.
5. Ben-Baruch G, Schiff E, Menashe Y, Menczer J: Immediate and late outcome of vaginal myomectomy for prolapsed pedunculated submucous myoma. Obstet Gynecol, 72(6):858- 861, 1988.
Harun TOY ve Ark.
